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Dubuque Bank & Trust Debit Card Application

Primary Cardholder Information

Checking Account Number:

Name (Last, First M.):

Social Security Number:

Date of Birth (mm/dd/yyyy):

Address:

City, State:

Zip-Plus4:

Home Phone Number:

( ) -

E-Mail Address:

Employer:

I am a Citizen of the United States of America.

Secondary Cardholder Information (if applicable)

Please issue an additional card in the name of:

Name (Last, First M.):

Social Security Number:

Date of Birth (mm/dd/yyyy):

Home Phone Number:

( ) -

Employer:

My Co-Applicant is a Citizen of the United States of America.

I (We) agree that the use of any Debit Card ("Card") issued in response to this application will constitute my (our) agreement to be jointly and severally bound by the terms and conditions of the Debit Card Agreement delivered with the Card. It is certified that the above information is complete and true, and is given to induce you to issue said Card(s). I (We) authorize you to make whatever credit and/or investigative inquires deemed necessary in connection with this application and to exchange with others regarding my (our) Card transactions. Unless I (We) contact a Personal Banker to select a PIN, one will be assigned to me (us). I (We) understand that this Card is not a Credit Card, and that no commitment to extend credit to me (us) will be made by your issuance of the Check Card(s) requested.

I (We) aknowledge and agree to the terms and conditions as outlined above.

If you would like access to additional Dubuque Bank and Trust accounts (checking, money market or savings accounts) at more than 90,000 ATMs worldwide, enter those account numbers below:

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